Intake/Referral Form

INTAKE/REFERRAL FORM

MULTNOMAH COUNTYUSE ONLY: / Open to CPMS?
CONSULTANT
INITIALS / PROGRAM / OPEN DATE / Yes No

LAST NAME

FIRST NAME

MIDDLE

/ DOB

BIRTH NAME

AKA

GENDER

/ M F

INDIVIDUAL’S ADDRESS

CITY

STATE /

ZIP

/ INDIVIDUAL’S PHONE
LIVES WITH
GUARDIAN
EMERGENCY CONTACT
OTHER / NAME: / RELATIONSHIP TO CLIENT:
ADDRESS: / PHONE #:
LIVES WITH
GUARDIAN
EMERGENCY CONTACT
OTHER / NAME: / RELATIONSHIP TO CLIENT:
ADDRESS: / PHONE #:
LIVES WITH
GUARDIAN
EMERGENCY CONTACT
OTHER / NAME: / RELATIONSHIP TO CLIENT:
ADDRESS: / PHONE #:
HEALTH INSURANCE
INSURER — PHYSICAL HEALTH
05 VA ...... >
08 Medicaid (OHP/Open Card) ...... >
11 Private Insurance ...... >
(Name):
12 Other Public Assistance (like CHIP/FHIAP)...... >
13 None / INSURANCE # / If OHP, select physical health plan:
Care Oregon
Family Care
Open Card
Kaiser
Providence
Other
INSURER — MENTAL HEALTH
05 VA ...... >
08 Medicaid (OHP/Open Card) ...... >
11 Private Insurance ...... >
(Name):
12 Other Public Assistance (like CHIP/FHIAP)...... >
13 None / INSURANCE # / If OHP, select mental health plan:
Family Care
Open Card
Verity
Other
REQUIRED
Name of Medical Provider
Address City State ZIP
Phone After-Hours Phone
ISA REFERRALS ONLY
Child is being prescribed psychotropic medication: Yes No
Name of Prescriber ______Phone______
Date of last medication check ____/_____/_____
Emergency Dental Resources:
Name: Phone: After-Hours Phone
INDIVIDUAL’S NAME: / DOB:

INTAKE CONTINUED

SCHOOL / SCHOOL DISTRICT / TEACHER

SCHOOL STATUS

ATTENDANCE

CLASSIFICATION

SCHOOL TYPE

/ HIGHEST GRADE COMPLETED
Kindergarten or less, use 00
Individual In School/Training?
Yes No
1 Full-Time / 1 Reg. Attendance / 1 Public School / 01 Family Day Care / 08 Special Ed
2 Part-Time / 2 Irreg. Attendance / 2 Private School / 02 Day Care / 09 Alternative
3 Discontinued / 3 Not Attending / 3 Home School / 03 Preschool / 10 Voc Prog
4 Never In / 4 Suspended / 4 None of Above / 04 Headstart / 11 GED Prog
5 Suspended / 5 Expelled / 05 Kindergarten / 12 Day Tx
06 Regular / 13 Not in School
99 Unknown
AGENCY INVOLVEMENT(Check as many as apply) / SUN / School Counselor / DD Services / MCCCF Outreach Specialist
A&D / DHS Self-Sufficiency / Special Ed (IEP or 504 Plan) / Physician / None
DHS / Juvenile Court / Health Agency / Other
DHS WORKER /

PHONE

DD/JJD/PO WORKER /

PHONE

LIVING ARRANGEMENT:
01 Alone / 05 Institutions
02 Spouse / 06 Friend or Other
03 Parents, Relatives / 21 Treatment Foster Care
04 Non-Relative Foster Home / 97 Homeless/Shelter
/ EMPLOYABILITY FACTOR:
0 Employable or working now / 5 Incarcerated
1 Student / 6 Seasonal worker (Migrant)
2 Homemaker / 7 Temporary layoff
3 Retired / 9 Unknown
4 Unable for phys. or psych. reasons
MARITAL STATUS:
1 Never Married / 4 Divorced
2 Married / 5 Separated
3 Widowed / 6 Living as Married
/ EMPLOYMENT STATUS:
1 Full-Time 35+ hrs / 4 Not employed but has sought work
2 Part-Time 17-34 hrs / 5 Not employed and has NOT sought work
3 Irregular—less than 17 hrs
Ethnicity (CPMS Required Codes):
01 White (Non-Hispanic) / 05 Asian / 09 Other Hispanic
02 Black (Non-Hispanic) / 06 Hispanic (Mexican) / 10 Southeast Asian
03 Native American / 07 Hispanic (Puerto Rican) / 11 Other Race/Ethnicity
04 Alaskan Native / 08 Hispanic (Cuban) / 12 Hawaiian/Other Pacific
Islander
/ Primary Language:
English
Other (specify)
English Proficiency High Medium Low
Is Translator/Interpreter needed? Yes No
Estimated Gross Household Monthly Income / $ / Total number of people in each age group who depend on household income.
Refused / Unknown / 0-6 / 7-17 / 18-64 / 65+
PRIMARY SOURCE OF HOUSEHOLD INCOME: (CHECK ONLY ONE)
Wages / Other
Public Assistance / None
MILITARY STATUS: N/A (17 and under only) No Military History Veteran Active, please specify:
ELIGIBILITY CODE: Individual with: / 04 Severe & Persistent Mental Illness/SE Disorder
16 Priority One Individual / 17 Priority Two Individual
18 Priority Three Individual
REFERRAL INFORMATIONSOURCE: (Please mark only one)
00 Unknown / 08 Support Programs for Children (Child Welfare) / 38 Self Help Groups (non-A&D)
04 Developmental Disabilities / 31 Primary Care Provider/Specialist/Phys Hlth Provider / 48 Fully Capitated Health Plan
05 School / 32 Self / 49 MHO
06 Other Comm. Agencies (e.g. Alcohol, Drug) / 33 Family/Friend / 99 Other
07 Support Programs for Adults (TANF/Food Stamps) / 37 Youth Service Agencies, Centers, or Teams
AGENCY NAME/CONTACT INFORMATION:
REASON FOR REFERRAL:
ISA REFERRALS ONLY:
REFERRING FOR: ISA Referral Wraparound Residential Day Treatment ICTS Other
INDIVIDUAL’S NAME: / DOB:

INTAKE CONTINUED

DIAGNOSTIC IMPRESSION / Primary / Secondary / Must have a Primary Diagnostic Impression
01 / Not Mentally Ill / Diagnosis Deferred / 06 / Mood Disorders / 14 / Disorders usually dx in infancy/childhood/adolescence
02 / Delirium, Dementia, Amnestic & Other Disorders / 09 / Anxiety Disorders / 16 / Eating Disorder
03 / Substance-Related Disorders / 10 / Adjustment Disorders / 17 / Other
05 / Schizophrenia and Other Psychotic Disorders / 11 / Personality Disorders / 18 / Unknown
GAF / CGAS
(Age 17 and over) / (Age 4-16)

ISA ONLY

______

SIGNATURE OF REFERRAL SOURCE PRINTED NAME PHONE DATE

INTAKE-REFERRAL FORM Rev. 4-19-13PAGE 1 OF 3